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MAP,-12-2014 08:00A FROM: TO:4683433 P.1/4 <br /> SAN JOAQUIN <br /> ENVIRONMENTAL HEALTH DEPARTMENT REQEIVED <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si-gov.org/ehd <br /> Mai 12 20t4 <br /> ENVIRONMENTAL <br /> RETURN TO COMPLIANCE CERTIFICATION HEALTH DEPAFffMEW <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Z /ZL/ Inspected By:�T N'A^i <br /> Facility Address.—2-7,26 of. EPA ID#: C At_000 VOA-7�2- <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork V— Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: 7Zc,6o..A til • l z Title: <br /> Signature: -. Date: <br /> ti <br /> EHD 22-02-OD5 Rev D8111 <br />